Title: Outbreak Investigation Operational Aspects 12th EPIET Introductory Course Lazareto, Spain
1Outbreak Investigation Operational Aspects
12th EPIET Introductory CourseLazareto,
Spain
Marta Valenciano, Susan Hahné, Jet de Valk, Mike
Ryan,
2Intervention epidemiology
- Definition
- The timely use of epidemiology
to solve urgent public health problems - Objective
- To maximise the scientific quality of
the investigation
in a complex environment
3What is an outbreak ?
- Occurrence of more cases of
disease than expected - over a particular period of time
- in a given area
- among a specific group of people
-
4Why investigate outbreaks?
- Stop the outbreak
- Understand what happened and why
- Prevent future outbreaks
- Improve our knowledge
- Improve surveillance
and outbreak detection - Training
5Outbreak Detection and Response
6Outbreak Detection and Response
7Objectives for this session
- Yesterday
- Methodological aspects
- Today
- Scenarios for your involvement
- Challenges in getting organised
during outbreak investigation - Preparing and organising yourself
for field work - Systematic approach to operational aspects
8Scenarios
Local Outbreak - Local authorities coordinate - Your are asked to assist / help
National Outbreak - Your institute coordinates You are asked to lead
International / European outbreak involving your country - ECDC coordinates - Your institute collaborates - You participate
Outbreak in another country The authorities in that country coordinate You are asked to assist
9e.g. EPIET fellow involvement
Local - Local authorities Hepatitis A in Bretagne
National - Your institute S. Typhi
International / European outbreak involving your country - ECDC coordinates Meningococal infections in pilgrims returning from Haj
Another country - The authorities in that country coordinate Leptospirosis in Nicaragua (French Ministry mission) Rift Valley Fever, Kenya (WHO mission)
10Operational challenges
- Unexpected event
- Need to investigate quickly
- Pressure for answers
- Multiple agencies
- Work carried out at many levels
- You are in the media spotlight
- Legal implications
11Operational challenges
- You may arrive late
- rumours?
- Local sensitivities
- Foreign country
- Need to feedback to various people
- Stress, long working hours,
finding time to rest and relax
12Unexplained illness in a high
school in Normandie, 2001
- 5/03 15 ill headache, nausea, abdominal pain
- 8/03 35 ill
- school closed
- investigation for toxic products
- medical examination of all ill students
- 15/03 45 ill
- 16/03 one student found dead
13Toxic products
Dead
Sick
Surveillance
Investigation
Exposed
Prediction
Clinicians
Epidemiology
Psychological support unit
Co-ordination
Laboratory clinical environmental
Environmental health
Parents Students
Clinical
Specimen transfer
General population
Principal Teachers
Diagnostic
Authorities
Media
Autopsy
Decisions School closure Medical examinations
Police, legal authorities
14Systematic approach
- Reasons for inviting you
- Terms of reference ?
- Preparing to leave for the field
- When you arrive
- In the field
- Outbreak Control Team
- Information management
- Leaving the field
- Back home
15Reasons for inviting you
- Expertise
- More resources
- Share responsibility
- Political or mass media pressure
- Mandatory or in guidelines
- Need to confirm local findings
- Specialised investigations
16Reasons for inviting youNormandie, 2001
- Expertise
- More resources
- Share responsibility
- Political or mass media pressure
17Terms of referenceClarify before accepting
- What are their expectations
- Expertise, tasks, time?
- What local resources are available?
- What has already been done?
- What resources do you need to bring?
- What is your role ?
- Who is in charge?
18Clarify before accepting,Normandie, 2001
- Expectations
- Epidemiological expertise
- Experience with mass sociogenic illness (MSI)
- Human ressources 5 persons
- Environmental investigation already started
- Computers, phones, car ...
- DMO in charge
19You are going to the field !
20Preparing to leave
- Consult colleagues
(microbiologist, vet, entomologist.) - Review pertinent litterature
- Decide who will lead the team
- Identify who provides support
in the head office - One page report before leaving
- objectives
- Arrange initial meeting for your arrival
21Preparing to leave, Normandie 2001
- Consult infectious disease experts, pathologist,
toxicologist - Review litterature causes of sudden death
- Support in head office 3 departments..
- One page report before leaving
- Arrange initial meeting for your arrival
22Bring your epi-pack
- Computer, calculator, mobile phone
- Software
- USB, CDs
- Notebook
- File templates
- Standard questionnaires
- Handbooks, relevant articles
- Camera
- (Laboratory equipment)
- Telephone, address list
- reference centers persons
- Maps, GPS
- Others... (money, health kit,)
23When you arrive
- Provide help - dont take charge
- Meet with key people
- Review and update status of problem
- Assess sensitivities
- Identify local resources and skills
- Discuss liaison
- Set up communications with base
24Arrival to Normandie
- Meeting with
- College principal
- Parents
- Visiting the school
- Understand rumours
- second world war
25(No Transcript)
26Organising the Outbreak Control Team
- Membership
- Leadership
- Responsibilities
- Lines of communication
- Communication
- Decision making process
27The Outbreak Control Team Tasks
- Agree plan of Action
- Commit resources
- Co-ordinate further investigation and response
- Report to and advise higher authorities
- ECDC and WHO alerts ?
- Maintain communication with
- other investigators
- stakeholders
- general public
- the media
28The Outbreak Control Team MSI Normandie
29The Outbreak Control TeamMSI Normandie
- Plan of action
- Describe events and exposures
- Retrospective cohort study
- Environmental investigation and sampling
- Systematic review of clinical findings
- Autopsy deceased student
- Psychological support
- Communication and information
30The Outbreak Control Centre - I
- Headquarters of the investigation
- Where
- How big
- Accessibility/Security
- Separation from normal work
- Catering
31The Outbreak Control Centre - II
- Equipment
- Computers with Internet connection
- Telephones, telefax
- Copy machine
- Reference materials
- Office furniture and stationery
32Information \ Data
- Types of information
- epidemiological
- operational
- Managing information (databases)
- Briefing, feed-back
- Communicating with the media
- one person !
- Writing reports ongoing process
33Epidemiological data
- Line listing is vital
- cases/contacts
- lab results, questionnaires available
- in excel
34(No Transcript)
35Operational information
- Contacts name, position, contact details
- Types of files
- epidemiological (questionnaires, data, protocols)
- interviews, meetings, press
- source and date
- emails
- Meetings
- minutes
- actions and those responsible
- Decisions and rationale
(information available at the time
of decision making) - All steps taken in the investigation
36Managing data \ data bases
- Software
- Database design
- Data
- entry and validation
- multiple data bases how linked?
- analysis
- programmes
- Backups / confidentiality / access
- Overall responsibility for data management
- Sometimes professional data manager
37Operational informationStorage and organisation
- Computer, laptop, web?
- Inventory of files
- Log book!
- every day
38Information Management The Media
- Appoint one (professional) spokesperson
- prepare briefings for him / her
- Coordinate with other agencies
- Inform early and often
- interviews
- press statements
- press briefings - regularly
- Be clear about what is
- fact
- speculation
- not known
39Normandie, 2001The media and the general public
- Different spoke persons
- DMO decision maker
- parents
- school authorities
- Epi investigator (experts..)
- media
- Conflicting information from other investigators
40Leaving the field
- Debriefing meeting
- Preliminary report
- Commit to produce final report
- Archive data
41Back home
- Inform your supervisor and colleagues
- debriefing
- Follow up
- lab, clinical other studies results
- Finalise the report ASAP
- Beware of confidentiality
- anonymise database
- anonymise questionnaires
42Normandie, 2001
- Deceased student congenital heart malformation
- Mass sociogenic illness
- Triggering factors
poor ventilation,
high temperature - Environmental contamination below toxic levels
- Children dispatched to other schools
malaises reported - School reopened after renovation
43Normandie lessons learned
- Involve other (competing) investigators
- Consult all partners and other investigators
before communicating important results - Stick to basic principals
- test your questionnaire - Back up from headquarters
- Distinguish investigators / decision makers
- Follow up after return
44Summary
- Outbreak investigations are challenging
- Preparation and good operational skills help
- Offer help, do not take charge
- Stay organised
- Dont come back until the job ids done
- Write your report all the time
- Take time to have a rest !!!
45Meet minister
Outbreak control team meeting - urgent!
TV inter view
Laboratory confirmation
Source
Control measures ?